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AdL ( bloc NIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS -TANK PAGE 1 (h ro pages per tank) Page _ Of TYPE OF ACTION ❑1.NEW SITE PERMIT ❑ 4. AMENDED PERMIT CHANGE OF INFORMATION) ❑ 6. TEMPORARY SITE CLOSURE (Check one lrem only) ❑ T. PERMANENTLY CLOSED ON SITE in ❑3.RENEWAL PERMIT (Specdyreesan brkcM un only) (Spsd1 - rlpaal use only) ❑ 8. TANKREMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID# 1 Y. LOCATION WITHIN SITE(Op#ona8 j 431 Z I.TANK DESCRIPTION TANK ID# TANKMANUFACTURER / COMPARTMENTALIZED TANK El Y.. 11 No -Fye It'Yes',complete one papa for seen mmpamment. DATE INSTALLED(YEARMO) TANK CAPACITY IN GALLONS NUMBER OF COMPARTMENTS ADDITIONAL DESCRIPTION(For local use aMy)- IL TANK CONTENTS TANK USE 432 PETROLEUM TYPE ��s...,(( ❑ 1. MOTOR VEHICLE FUEL ❑Is. REGUTARUNLEADED 4�T LEADED ❑ 5. JET FUEL (#marked,comPlele Pe#oleum Type) lb. PREMIUM UNLEADED ❑ 3. DIESEL ❑ S. AVIATIONFUEL ❑ 2. NON-FUELPETROLEUM 1c MIDGRADEUNLEADED ❑ 4. GASOHOL 11 N. OTHER ❑ 3.CHEMICAL PRODUCT ❑ 4. HAZARDOUS WASTE(Indudes COMMON NAME(hpm Hazallous Materials lowntory page) CAB#(nam lhwsrasos Mahood.lnwnforypepe) Used Od) 13 95 UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1. SINGLE WALL ❑ 3. SINGLE WALL WITH ❑ 5. SINGLE WALL WITH INTERNAL BLADDER SYSTEM (Check one dem only) ❑ 2, DOUBLE WALL EXTERIOR MEMBRANE LINER 1195. UNKNOWN ❑ 4. SINGLE WALL IN A VAULT ❑99. OTHER TANK MATERIAL-primary tank 0 1 BARE STEEL ❑ 3. FIBERGLASS I PLASTIC ❑ S. CONCRETE ❑95, UNKNOWN (Check am item only) ❑ 2. STAINLESS STEEL ❑4. STEEL CI-AD W/FIBERGLASS ❑ 8. FRP COMPATIBLE W l0D%METHANOL ❑99. OTHER REINFORCED PLASTIC(FRP) TANK MATERIAL-secondary tank 0 i BARE STEEL ❑ 3. FIBERGLASS/PLASTIC ❑ S. FRP COMPATIBLE W/1011%METHANOL 09. UNKNOWN (Check am hem oaW ❑ 2. STAINLESS STEEL ❑ 4. STEEL CLAD W/FIBERGLASS ❑ 9. FRP NON-CORRODIBLE JACKET ❑B9. OTHER REINFORCED PLASTIC(FRP) 1110. COATED STEEL ❑ S. CONCRETE TANK INTERIOR LINING 13 1. RUBBER LINED ❑ 3. EPDXY LINING ❑ S. GLASS LINING ❑95. UNKNOWN423 DATE INSTALLED OR COATING ❑ 2. ALKYD LINING 114. PHENOLIC LINING 118. UNLINED 1389. OTHER (Cheat .Ilam oaf) For kcal use w OTHER CORROSION ❑ 1 MANUFACTURED CATHODIC ❑ 3. FIBERGIASS REINFORCED PLASTIC ❑95. UNKNOWN 434 GATE INSTALLED PROTECTION IF APPLICABLE PROTECTION ❑ d. IMPRESSED CURRENT ❑99. OTHER (Checkom item only) ❑ 2.SACRIFICIALANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLED TYPE(Forlocal use only) OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check e6 that apply) 11 1 SPILLCONTAINMENT ❑ 1. ALARM ❑ 3. FILL TUBE SHUT OFF VALVE ❑ 2. DROPTUBE ❑ 2. BALL FLOAT ❑ 4. EXEMPT ❑ 3. STRIKER PLATE IV. TANK LEAN DETECTION IF SINGLE WALL TANK(Check all theta I): IF DOUBLE WALL TANK OR TANK WITH BUDDER(Cbeck oneitemon : ❑ 1, VISUAL(EXPOSED PORTION ONLY) ❑ S. MANUAL TANK GAUGING(MTG) ❑ 1. VISUAL(SINGLE WALLIN VAULT ONLY) ❑ 2. AUTOMATIC TANK GAUGING(ATG) ❑ 6. VADOSE ZONE ❑ 2. CONTINUOUS INTERSTITIAL MONITORING ❑ 3. CONTINUOUS ATG ❑ T. GROUNDWATER ❑ 3. MANUALMONITORING ❑ 4. STATISTICAL INVENTORY RECONCILIATION(SIR). ❑ S. TANKTESTING BIENNIAL TANK TESTING ❑BB. OTHER V.TANK CLOSURE INFORMATION/PERMANENT CLOSURE JN PLACE ESTIMATED DATE LAST USED(YRIMO/DAY) ESTIMATED QUANTITY OF SUBSTANCE REMAINING 435 TANK FILLED WITH INERT MATERIAL? pelkne ❑Vee ❑No CUPAFORM(4199) �' Formerly SWRCB Forn B